Lisa Blumberg: Whether Suicide Can Be Rational Is the Wrong Question

In the article “Rational Suicide in Later Life: A Systematic Review of the Literature” in the National Library of Medicine, the authors reviewed 23 studies on “rational suicide” with the stated aim of better understanding the concept of rational suicide in older adults. The piece defines rational suicide as “a sane, well-thought-out and fairly stable decision by an individual who is mentally competent, and who is capable of reasoning and choosing the best alternative among the many available with no ambivalence” (italics mine for emphasis). Unfortunately, the piece contributes nothing to better understanding of the concept; its focus seems to be on determining based on the writers’ review of the literature, whether there is such a thing as “rational suicide.”

The writers of the article note inconsistencies in the studies, the incidence of depression in older adults and the tendency to under diagnosed and undertreat it, bias among health care providers, ageism and the possibility of a slippery slope. The authors conclude though that while clinicians should avoid making premature conclusions about the “rationality” of patients’ decisions to die, nonetheless, the possibility of rational suicide cannot be precluded.

The clear implication is that a clinician can and perhaps should respond to a person’s suicide ideation differently based on whether it is “rational” or “pathological”. The writers give no guidance about how a provider should objectively determine if suicide is “rational” beyond encouraging the provider to consider all of the patient’s circumstances. Since the article is just intended to be a review of the literature, they do not explicitly state what a clinician should do if they find a suicide to be “rational”. However, they do note that the concept of rational suicide is “obviously linked” to the debate over euthanasia and assisted suicide. That is the nub.

The attempt to divide suicide into two categories – the rational and the pathological – is paternalistic and ableist in itself. It is a red herring. Moreover, it rings hollow to focus on a decision to die being rational, when the reason why it can be considered rational is because society has made choices and pursued policies that make it seem rational. In Canada, people have “chosen” euthanasia because they could not obtain the funding for the in-home aide support they needed to stay out of a nursing home. They acted out of the quite well-founded fear of what life is like in a nursing home. It can be said they acted rationally but not freely. An alternative was theoretically available but the community would not give it to them.

At the extreme, some ethicists argue that granting euthanasia requests driven by unjust social circumstances can be seen as a form of “harm reduction.” To be fair though, there is nothing in the article that suggests that the authors would countenance such nihilism.

The authors mention that 55% of late life suicides are associated with physical illness and older people and those with chronic/terminal illness may not have psychiatric comorbidity. Physical illness is more likely to eventually lead to suicidal behavior when it causes functional disabilities threatening the individual’s independence, autonomy and perceived dignity, quality of and pleasure with life, their sense of meaning, usefulness and purpose in life, personal value and self-esteem. In other words, people think about suicide not because death may be near but because they are unsure about how to deal with the practical problems and devaluation that come with living with a possibly progressive disability in our society. It’s about all about fear of disability.

Clinicians should not be encouraged to engage in speculation about whether a person’s desire to die is rational. Instead, the question they should ask is what can society do to change the crushing devaluation too many experience as they acquire disabilities? And what resources can be brought to bear so that the person can still live a life that comes as close as possible to the life that the person would like to live.